Colostomy & Ileostomy Creation/Reversal
What the Examiner Expects
Creation of an abdominal wall stoma from either colon (colostomy) or ileum (ileostomy) for fecal diversion, and subsequent reversal to restore intestinal continuity. The examiner expects you to differentiate end from loop stomas, know the indications for each, and understand stoma maturation technique. An ileostomy is everted (Brooke technique) to create a 2–3 cm spout that directs effluent into the appliance and protects skin from corrosive small bowel contents. A colostomy is matured flush to the skin. Stoma site selection (right lower quadrant for ileostomy, left for colostomy) should avoid skin creases, bony prominences, scars, and the belt line.
Key Examiner Focus Points
- End stoma: bowel brought out as a single lumen (matured, everted 2–3 cm for ileostomy, flush for colostomy)
- Loop stoma: both limbs brought through one opening — used for temporary diversion
- Preoperative stoma marking by enterostomal therapy nurse is essential
- High-output ileostomy (> 1.5 L/day): dehydration, electrolyte abnormalities (hyponatremia, hypokalemia, metabolic acidosis)
- Parastomal hernia is the most common long-term complication
Common Curveballs
Patient with an ileostomy presents to the ED with hyponatremia, hypokalemia, and AKI
High-output ileostomy with dehydration. Aggressive IV fluid resuscitation with isotonic crystalloid, correct electrolytes, and add loperamide and fiber supplements to thicken the output. If refractory, add codeine or tincture of opium. Dietary counseling to increase salt and fluid intake.
The stoma retracts below skin level in the early postoperative period
Stoma retraction increases risk of peristomal skin breakdown and poor appliance seal. If minor, manage with convex pouching system. If significant retraction with fascial dehiscence or ischemia, may require surgical revision.
Parastomal hernia develops — how do you manage?
Initially manage with a hernia belt and proper pouching. If symptomatic, surgical options include local repair with mesh reinforcement (Sugarbaker or keyhole technique), stoma relocation, or laparoscopic repair. Recurrence rates are high for all techniques.